Provider Demographics
NPI:1699459636
Name:ANDERSON, MICHAEL VINCENT (APN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VINCENT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9977 WOODS DR
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1057
Mailing Address - Country:US
Mailing Address - Phone:224-364-2273
Mailing Address - Fax:
Practice Address - Street 1:9977 WOODS DR
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1057
Practice Address - Country:US
Practice Address - Phone:224-364-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027531363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty